Renew My Benefits

Renew My Benefits
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 1 of 11
Case Information
Case name Social Security number
Your worker uses the information you report on this form to see if your household can still get help
with food, SoonerCare (Medicaid), or child care subsidy benefits. Please fill out, sign, and return this
form to the OKDHS office shown above. Attach additional sheets of paper to this form if you need
more space to answer questions. Return this form by or your benefits will
stop on .
If you need help filling out this form, call your OKDHS office. [Nota Importante: Si usted no puede
leer esta forma, póngase en contacto con su trabajador social, llamando al número de teléfono que
se menciona arriba.]
Tell Us About Where You Live
Mailing address City State ZIP code
Street address City State ZIP code
Home phone Work phone Cell phone Message phone
Finding directions to your home
Date
Case name
Case #
County #
Supervisor # Worker #
Email address
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 2 of 11
People Getting Benefits Now
List the people getting benefits in your case.
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
Tell Us About Other People Living in Your Home
Please fill out the information below for everyone else living in your home that is not already shown
above. If you want benefits for him or her, you must check the U.S. citizen block and fill in the Social
Security number for each person. Your worker will contact you.
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 3 of 11
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
Tell Us About Your Household's Income
Income is all the money you and the people living with you get each month. Types of income include
money earned from working for someone else, working for yourself, and any unearned income.
Some types of unearned income are: child support, Social Security, Supplemental Security Income
(SSI), State Supplemental Payment (SSP), Temporary Assistance for Needy Families (TANF), Tribal
TANF, veteran's benefits, unemployment benefits, military allotments, alimony, gambling winnings,
Workers’ Compensation, contributions, interest, dividends, pension, rental income, foster care or
adoption subsidy payments, and income from mineral rights or oil and gas leases.
Tell us about your household's income for the month of .
If income has stopped, fill out the information below:
First name Last name
Income type Final amount Date of final amount
First name Last name
Income type Final amount Date of final amount
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 4 of 11
If you have income, fill out the information below.
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 5 of 11
If anyone age 16 or older is a student, please fill out the information below.
Student's first name Student's last name
Full Part time
Full or part time?
Name of school
Student's first name Student's last name
Full Part time
Full or part time?
Name of school
Tell Us About Your Bills and Expenses
Please fill out the information below about your bills and expenses.
Child care expense.
How much do you pay each month for child care?
Adult day care expense.
How much do you pay each month for day care for an elderly or disabled
person who lives with you?
Medical expense.
Tell us the medical costs not paid by insurance for everyone who is disabled or age 60 and older.
These could be doctor or hospital bills, medicine, transportation, health insurance premiums, or
other medical services.
Name
Type of expense Monthly expense
Name
Type of expense Monthly expense
Name
Type of expense Monthly expense
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 6 of 11
Child support expense.
Does anyone in your household pay court-ordered child support? Yes No
If yes, please fill out the information below:
Who pays? To whom?
How much? How often? Street address of person you pay
City State ZIP code Phone number
Housing expenses.
Do you get help to pay for housing? Yes No
If yes,
Who pays? To whom?
How much?
Do you or anyone in your household pay for housing? Yes No
How much do you pay for housing? Amount per
Homeowner insurance, if separate: Amount per
Property tax, if separate: Amount per
Person or company you pay rent/mortgage to:
What is their phone number?
Do you expect to pay the same amount for housing next month? Yes No
Are you responsible for paying heating or cooling expenses? Yes No
Utility expenses.
What utility expenses do you pay: Phone Electric Gas/butane/propane
Wood Garbage/water Other
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 7 of 11
Tell Us About Your Resources
A resource is anything anyone owns, owns jointly with someone else, or is buying that can be sold,
traded, or changed into cash. Do not report personal property, such as jewelry, furniture, household
appliances, or clothing. Check the boxes for the resources you have:
Checking accounts Savings accounts Stocks/bonds
Individual retirement accounts (IRAs) Mineral rights
Other
Trust funds
Life insurance/burial policies Land Livestock
Report all vehicles here. List all cars, trucks, boats, vans, campers, motorcycles, or other
vehicles owned by household members.
Make Model Year Loan balance
Report all vehicles here. List all cars, trucks, boats, vans, campers, motorcycles, or other
vehicles owned by household members.
Make Model Year Loan balance
Tell Us About Your Health Insurance
Is anyone covered by health or dental insurance? Yes No
If yes, please complete the following: If more space is needed, attach additional pages.
City State ZIP code
Name of company Address of insurance company
Who is covered? Insurance type Effective date
Policy holder name
Policy number Relationship to insured
Health and dental screening:
People under age 21 who have SoonerCare (Medicaid) can receive health and dental screening
exams and follow-up treatment under the Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) Program. If you want EPSDT, call your medical provider to set up an
appointment. Please check no if you DO NOT want EPSDT services. No
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 8 of 11
Tell Us About Your Need for Child Care
Which children need child care?
List the days and hours child care is needed:
First parent/caretaker
Days and hours of work/school,
including travel time
Second parent/caretaker
Days and hours of work/school,
including travel time
Who is your child care provider?
First name Last name
Street address City State ZIP code
Phone number
First name Last name
Street address City State ZIP code
Phone number
Is anyone other than you or OKDHS currently paying any money directly to your
child care provider? Yes No
If yes, list name and how much he or she is paying:
Name Amount
Who is your emergency contact? Phone number
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 9 of 11
Proof Needed
You MUST give us proof of all income if any member of your household:
receives food or child care benefits; and/or
receives SoonerCare (Medicaid) and is disabled or age 65 or older.
You MUST give us proof of all resources if any member of your household:
receives SoonerCare (Medicaid) and is disabled or age 65 or older.
If anyone: then you must attach:
is working pay stubs for all checks anyone got in the month of
; or
statements from employers showing pay dates and
earnings before taxes for the month of
.
has stopped working in the last five
months
final pay check stub and employer’s statement.
is self-employed a federal income tax return for the previous year; or
income and expense records if taxes have not been
filed.
gets unearned income an award letter;
a letter from the person or agency who provides the
income;
a check stub or copy of check; or
a court order.
has stopped getting unearned income a statement from the person or agency that gave you
the income showing it has stopped.
over age 60 or disabled has medical
expenses not paid by insurance and
wants food benefits
prescription printouts for the past 60 days;
insurance premium statements;
copy of doctor or hospital bills; and
statement of transportation costs.
is paying court ordered child support court order, if not given to us before; and
proof of regular child support payments.
has resources checking and savings account statements or other
financial statements for the month of
; or
copy of life insurance policy, if not given to us before;
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 10 of 11
copy of property deeds and titles, if not given to us
before.
copy of burial policy if not given to us before; or
has any vehicles such as cars, trucks,
boats, vans, motorcycles, RVs, or
campers
proof of amount owed on loans.
gets child care subsidy benefits proof of your current work/school/training schedule.
The following information applies to the Supplemental Nutrition Assistance Program (SNAP)
only:
I understand that there are specific penalties for fraudulent activities, such as hiding information,
making false statements, or the misuse of SNAP benefits. For SNAP, more penalties will result for
more serious offenses, such as SNAP trafficking. For most situations, the penalties are loss of or
reduction of benefits for:
one year for the first offense;
two years for the second offense; and
permanently for the third offense.
The collection of this information, including the SSN of each household member, is authorized under
the Food and Nutrition Act of 2008, as amended, Sections 2011 2036 of Title 7 of the United States
Code. The information is used to determine whether my household is eligible or continues to be
eligible to participate in SNAP. OKDHS verifies this information through computer matching
programs. This information will also be used to monitor compliance with program regulations and for
program management.
This information may be disclosed to other federal and state agencies for official
examination, and to law enforcement officials for the purpose of apprehending persons
fleeing to avoid the law.
If there is a food benefit overpayment, the information on this application, including all
SSNs, may be referred to federal and state agencies, as well as private claims collection
agencies, for claims collection action.
I understand food benefits are prorated from the date of application.
I understand that providing requested information, including the SSN of each household
member, is voluntary. However, failure to provide this information will result in the denial of
food benefits to my household.
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 11 of 11
The following information applies to the SNAP, SoonerCare (Medicaid), and Child Care
Subsidy programs.
I understand failure to complete and return this form with attached proof could result in closure of
benefits. I agree to provide the proof necessary to establish continued eligibility.
My answers on this form are true, correct, and complete to the best of my knowledge. I understand
my rights and responsibilities and penalty warnings from my last application apply to this review.
I understand that the SSN of persons included in the case will be used to match with income data
from other government agencies, such as the Social Security Administration, Internal Revenue
Service, Oklahoma Employment Security Commission, and data brokers. Information gathered will
be used to determine my eligibility for assistance.
I certify under penalty of perjury that I have truthfully reported the citizenship status of any additional
persons for whom I am requesting benefits. I understand I must advise OKDHS if anyone in my
household is not in lawful immigration status.
If OKDHS approves my household for benefits and it is later determined I made a false claim of U.S.
citizenship or lawful immigration status for anyone in my household, a complaint will be filed by
OKDHS with the U.S. Attorney, and I may be subject to criminal prosecution.
I authorize the release of any necessary information, documents, or forms to OKDHS from
individuals, businesses, schools, banking institutions, data brokers, public or private organizations,
Oklahoma state agencies, including personal and/or business income tax returns from the Oklahoma
Tax Commission, or federal agencies to determine my eligibility for assistance.
Signature of client, guardian, conservator, or authorized representative Date
Use when client cannot read or write or signs by mark:
Signature of witness Date
REMEMBER, for your benefits to continue, you must:
answer every question that applies to you;
attach all required proof;
attach additional sheets of paper you used to answer questions; and
sign the form and return it to your local OKDHS office by
or your benefits will stop on .

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Renew My Benefits
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 1 of 11
Case Information
Case name Social Security number
Your worker uses the information you report on this form to see if your household can still get help
with food, SoonerCare (Medicaid), or child care subsidy benefits. Please fill out, sign, and return this
form to the OKDHS office shown above. Attach additional sheets of paper to this form if you need
more space to answer questions. Return this form by or your benefits will
stop on .
If you need help filling out this form, call your OKDHS office. [Nota Importante: Si usted no puede
leer esta forma, póngase en contacto con su trabajador social, llamando al número de teléfono que
se menciona arriba.]
Tell Us About Where You Live
Mailing address City State ZIP code
Street address City State ZIP code
Home phone Work phone Cell phone Message phone
Finding directions to your home
Date
Case name
Case #
County #
Supervisor # Worker #
Email address
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 2 of 11
People Getting Benefits Now
List the people getting benefits in your case.
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
First name Last name
Does this person still live with you? Yes No
Tell Us About Other People Living in Your Home
Please fill out the information below for everyone else living in your home that is not already shown
above. If you want benefits for him or her, you must check the U.S. citizen block and fill in the Social
Security number for each person. Your worker will contact you.
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 3 of 11
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
First name Last name Date of birth
Yes No Social Security number
Is this person a U.S citizen?
Relationship to you
Tell Us About Your Household's Income
Income is all the money you and the people living with you get each month. Types of income include
money earned from working for someone else, working for yourself, and any unearned income.
Some types of unearned income are: child support, Social Security, Supplemental Security Income
(SSI), State Supplemental Payment (SSP), Temporary Assistance for Needy Families (TANF), Tribal
TANF, veteran's benefits, unemployment benefits, military allotments, alimony, gambling winnings,
Workers’ Compensation, contributions, interest, dividends, pension, rental income, foster care or
adoption subsidy payments, and income from mineral rights or oil and gas leases.
Tell us about your household's income for the month of .
If income has stopped, fill out the information below:
First name Last name
Income type Final amount Date of final amount
First name Last name
Income type Final amount Date of final amount
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 4 of 11
If you have income, fill out the information below.
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
First name of person getting income Last name of person getting income
Amount before taxes How often received Income type
Self-employment gross income last year Employer
Employer address City State ZIP code
Employer phone number
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 5 of 11
If anyone age 16 or older is a student, please fill out the information below.
Student's first name Student's last name
Full Part time
Full or part time?
Name of school
Student's first name Student's last name
Full Part time
Full or part time?
Name of school
Tell Us About Your Bills and Expenses
Please fill out the information below about your bills and expenses.
Child care expense.
How much do you pay each month for child care?
Adult day care expense.
How much do you pay each month for day care for an elderly or disabled
person who lives with you?
Medical expense.
Tell us the medical costs not paid by insurance for everyone who is disabled or age 60 and older.
These could be doctor or hospital bills, medicine, transportation, health insurance premiums, or
other medical services.
Name
Type of expense Monthly expense
Name
Type of expense Monthly expense
Name
Type of expense Monthly expense
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 6 of 11
Child support expense.
Does anyone in your household pay court-ordered child support? Yes No
If yes, please fill out the information below:
Who pays? To whom?
How much? How often? Street address of person you pay
City State ZIP code Phone number
Housing expenses.
Do you get help to pay for housing? Yes No
If yes,
Who pays? To whom?
How much?
Do you or anyone in your household pay for housing? Yes No
How much do you pay for housing? Amount per
Homeowner insurance, if separate: Amount per
Property tax, if separate: Amount per
Person or company you pay rent/mortgage to:
What is their phone number?
Do you expect to pay the same amount for housing next month? Yes No
Are you responsible for paying heating or cooling expenses? Yes No
Utility expenses.
What utility expenses do you pay: Phone Electric Gas/butane/propane
Wood Garbage/water Other
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 7 of 11
Tell Us About Your Resources
A resource is anything anyone owns, owns jointly with someone else, or is buying that can be sold,
traded, or changed into cash. Do not report personal property, such as jewelry, furniture, household
appliances, or clothing. Check the boxes for the resources you have:
Checking accounts Savings accounts Stocks/bonds
Individual retirement accounts (IRAs) Mineral rights
Other
Trust funds
Life insurance/burial policies Land Livestock
Report all vehicles here. List all cars, trucks, boats, vans, campers, motorcycles, or other
vehicles owned by household members.
Make Model Year Loan balance
Report all vehicles here. List all cars, trucks, boats, vans, campers, motorcycles, or other
vehicles owned by household members.
Make Model Year Loan balance
Tell Us About Your Health Insurance
Is anyone covered by health or dental insurance? Yes No
If yes, please complete the following: If more space is needed, attach additional pages.
City State ZIP code
Name of company Address of insurance company
Who is covered? Insurance type Effective date
Policy holder name
Policy number Relationship to insured
Health and dental screening:
People under age 21 who have SoonerCare (Medicaid) can receive health and dental screening
exams and follow-up treatment under the Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) Program. If you want EPSDT, call your medical provider to set up an
appointment. Please check no if you DO NOT want EPSDT services. No
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 8 of 11
Tell Us About Your Need for Child Care
Which children need child care?
List the days and hours child care is needed:
First parent/caretaker
Days and hours of work/school,
including travel time
Second parent/caretaker
Days and hours of work/school,
including travel time
Who is your child care provider?
First name Last name
Street address City State ZIP code
Phone number
First name Last name
Street address City State ZIP code
Phone number
Is anyone other than you or OKDHS currently paying any money directly to your
child care provider? Yes No
If yes, list name and how much he or she is paying:
Name Amount
Who is your emergency contact? Phone number
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 9 of 11
Proof Needed
You MUST give us proof of all income if any member of your household:
receives food or child care benefits; and/or
receives SoonerCare (Medicaid) and is disabled or age 65 or older.
You MUST give us proof of all resources if any member of your household:
receives SoonerCare (Medicaid) and is disabled or age 65 or older.
If anyone: then you must attach:
is working pay stubs for all checks anyone got in the month of
; or
statements from employers showing pay dates and
earnings before taxes for the month of
.
has stopped working in the last five
months
final pay check stub and employer’s statement.
is self-employed a federal income tax return for the previous year; or
income and expense records if taxes have not been
filed.
gets unearned income an award letter;
a letter from the person or agency who provides the
income;
a check stub or copy of check; or
a court order.
has stopped getting unearned income a statement from the person or agency that gave you
the income showing it has stopped.
over age 60 or disabled has medical
expenses not paid by insurance and
wants food benefits
prescription printouts for the past 60 days;
insurance premium statements;
copy of doctor or hospital bills; and
statement of transportation costs.
is paying court ordered child support court order, if not given to us before; and
proof of regular child support payments.
has resources checking and savings account statements or other
financial statements for the month of
; or
copy of life insurance policy, if not given to us before;
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 10 of 11
copy of property deeds and titles, if not given to us
before.
copy of burial policy if not given to us before; or
has any vehicles such as cars, trucks,
boats, vans, motorcycles, RVs, or
campers
proof of amount owed on loans.
gets child care subsidy benefits proof of your current work/school/training schedule.
The following information applies to the Supplemental Nutrition Assistance Program (SNAP)
only:
I understand that there are specific penalties for fraudulent activities, such as hiding information,
making false statements, or the misuse of SNAP benefits. For SNAP, more penalties will result for
more serious offenses, such as SNAP trafficking. For most situations, the penalties are loss of or
reduction of benefits for:
one year for the first offense;
two years for the second offense; and
permanently for the third offense.
The collection of this information, including the SSN of each household member, is authorized under
the Food and Nutrition Act of 2008, as amended, Sections 2011 2036 of Title 7 of the United States
Code. The information is used to determine whether my household is eligible or continues to be
eligible to participate in SNAP. OKDHS verifies this information through computer matching
programs. This information will also be used to monitor compliance with program regulations and for
program management.
This information may be disclosed to other federal and state agencies for official
examination, and to law enforcement officials for the purpose of apprehending persons
fleeing to avoid the law.
If there is a food benefit overpayment, the information on this application, including all
SSNs, may be referred to federal and state agencies, as well as private claims collection
agencies, for claims collection action.
I understand food benefits are prorated from the date of application.
I understand that providing requested information, including the SSN of each household
member, is voluntary. However, failure to provide this information will result in the denial of
food benefits to my household.
Form 08MP004E (FSS-BR-1) v.3 08/09/2012 Page 11 of 11
The following information applies to the SNAP, SoonerCare (Medicaid), and Child Care
Subsidy programs.
I understand failure to complete and return this form with attached proof could result in closure of
benefits. I agree to provide the proof necessary to establish continued eligibility.
My answers on this form are true, correct, and complete to the best of my knowledge. I understand
my rights and responsibilities and penalty warnings from my last application apply to this review.
I understand that the SSN of persons included in the case will be used to match with income data
from other government agencies, such as the Social Security Administration, Internal Revenue
Service, Oklahoma Employment Security Commission, and data brokers. Information gathered will
be used to determine my eligibility for assistance.
I certify under penalty of perjury that I have truthfully reported the citizenship status of any additional
persons for whom I am requesting benefits. I understand I must advise OKDHS if anyone in my
household is not in lawful immigration status.
If OKDHS approves my household for benefits and it is later determined I made a false claim of U.S.
citizenship or lawful immigration status for anyone in my household, a complaint will be filed by
OKDHS with the U.S. Attorney, and I may be subject to criminal prosecution.
I authorize the release of any necessary information, documents, or forms to OKDHS from
individuals, businesses, schools, banking institutions, data brokers, public or private organizations,
Oklahoma state agencies, including personal and/or business income tax returns from the Oklahoma
Tax Commission, or federal agencies to determine my eligibility for assistance.
Signature of client, guardian, conservator, or authorized representative Date
Use when client cannot read or write or signs by mark:
Signature of witness Date
REMEMBER, for your benefits to continue, you must:
answer every question that applies to you;
attach all required proof;
attach additional sheets of paper you used to answer questions; and
sign the form and return it to your local OKDHS office by
or your benefits will stop on .